Abstract

Chronic lung infection is the main indication for lobectomy in benign pulmonary disease. VATS has developed to the point where standard thoracic procedures are now being performed on a regular basis with minimally invasive surgery. The overall stay of the patient was minimized as compare to the open thoracotomy and hence procedure was cost effective in terms of hospital stay,6 less amount of antibiotics, analgesia given. We present a case report of the same.

Introduction

Chronic lung infection is the main indication for lobectomy in benign pulmonary disease and may be technically demanding due to inflammatory changes such as adhesions, lymph node enlargement and neovascularization. Thoracoscopic lobectomy in chronic inflammatory disease can be performed safely in selected patients, especially with Tuberculosis and bronchiectasis.

Case Report

A 26 year old male presented in the surgery OPD with a history of Haemoptysis since last 6-8 months, and patient was on Anti tuberculous drugs since last three months.

Examination: Averagely built and nourished with normal vital parameters.

Investigations:

Hb: 11.80 gm per cent

ESR: 32 at the end of one hour.

X-ray Chest : Pulmonary Koch’s at the right apical region.

C.E.C.T.: Revealed dense fibrosis at the right apical region. Right upper lobe a secondary fungal pathology can be considered. ?Possibility of old tuberculosis with reactivation.7

Video Fibreoptic Bronchoscopy: Right Bronchial tree mucosa seen congested, eroded, and clotted blood seen at the apical segment of Right upper lobe. No growth seen. Impression: Post Tuberculosis Bronchitis.

Endoscopy: Small Diverticulum in Antrum.

Surgery

Written informed consent taken for VATS, SOS Thoracotomy.

Patient is positioned in left lateral decubitus position with right arm extended. Single lung ventilation is established. Three ports are placed first 10 mm port at mid axillary line in the 6th intercostal space, second port of 5 mm anteriorly just below the nipple and third port at 5th intercostal space posteriorly in the mid scapular line. Right thoracoscopy performed. Right apical lobe was in dense adhesions with fibrosis all around. Adhesiolysis started at the apex with harmonic scalpel and apical lobe is isolated.3,7,10 Vessels from the thoracic wall are ligated with ligaclip and cut.

Rest of the feeding vessels and the tertiary bronchioles are stapled8,9,5 with 45 mm thick endopath. Haemostasis achieved and the stappled part is further sutured with vicryl 2-0. ICD tube kept in the right side of chest and ports closed.

Patient shifted to recovery room, Liquids orally started after 4 hrs of surgery. Subsequent X-ray chest taken, ICD removed on the 4th Post operative day2 and patient discharged on 5th postoperative day.6 During the stay patient was kept on NSAID’s 50 mg BD and was discharged on 50 mg of NSAID O.D. for 3 days on follow up patient was pain free.4

Pathology: Intense Inflammation, Fibrosis, and Calcification - Post TB.10

Discussion

Thoracoscopic lobectomy may have improved breathing function earlier as a result of the less invasive and less painful procedure. We have also noted a decrease in the need for narcotics in patients who have undergone thoracoscopic resection.4

Overall, we have been impressed by the decreased length of stay and have also noted a decrease in pain in our patients in comparison with patients who have undergone the traditional open approach.1,6

The pain-related morbidity, the mean duration of air leaks, the chest tube duration2 and the hospital stay were all less after the VATS procedure,9 compared to the open procedure (thoracotomy).

Conclusion

Chronic lung infection is the main indication for lobectomy in benign pulmonary disease and may be technically demanding due to inflammatory changes such as adhesions, lymph node enlargement and neovascularization.10

VATS has developed to the point where standard thoracic procedures are now being performed on a regular basis with minimally invasive surgery. Anatomic pulmonary resections by VATS have been developed in the hope of reducing morbidity, mortality, and hospital stay, while allowing a quicker return to regular activities for patients after procedures that formerly required major incisions.7 There is mounting evidence that VATS procedures do have benefit over open procedures. Thoracoscopic lobectomy in chronic inflammatory disease can be performed safely in selected patients, especially with bronchiectasis.3,5,7,10 The overall stay of the patient was minimized as compare to the open thoracotomy and hence procedure was cost effective in terms of hospital stay,6 less amount of antibiotics, analgesia given.4

Subsequent Follow up of patient was satisfactory and pain free.4

References

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8. Lewis J, Robert J Caccavale, et al. General Thoracic One Hundred Video-Assisted Thoracic Surgical Simultaneously Stapled Lobectomies without Rib Spreading Ralph. University Thoracic Surgical Service, St. Peter’s Medical Center, Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
9. Ralph J Lewsis, New Brunswick NJ. Simultaneously stapled lobectomy : A safe technique for video-assisted thoracic surgery, Department of Thoracic Surgery, St. Peter’s Medical Center, Robert Wood Johnson University Hospital, New Brunswick, NJ.
10. Weber A, Stamberger U, Inci I, et al. Thoracoscopic lobectomy for benign disease - a single centre study on 64 cases. Eur J Cardiothorac Surg 2001; 20 (3) : 443-8.

*Junior Consultant; **Senior Consultant in Department of Minimal Access and GI Surgery, Bombay Hospital Indore, Ringh Road, Indore, India.